MEDICARE: DR. ERICA KITCHELL WIEDL MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	23432	LA
2	207Q00000X	Family Medicine Physician	ME144522	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649250606
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERICA KITCHELL WIEDL MD

Provider Business Mailing Address
First Line	:	PO BOX 45443
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84145-0443
Country	:	US
Telephone Number	:	904-202-1032
Fax Number	:	904-376-4107

Provider Business Practice Location Address
First Line	:	851042 US HIGHWAY 17
Second Line	:
City	:	YULEE
State	:	FL
Zip	:	32097-2845
Country	:	US
Telephone Number	:	904-225-3824
Fax Number	:	904-390-7440

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/18/2006
Last Update Date	:	09/03/2020

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